Professional Documents
Culture Documents
Prevention ..................................................................................................................................................... 2 Screening Recommendations and Tests ...................................................................................................... 2 Diagnosis....................................................................................................................................................... 2 Treatment ...................................................................................................................................................... 4 Goals ......................................................................................................................................................... 4 Lifestyle modifications and non-pharmacologic options ............................................................................ 4 Blood glucose controlpharmacologic options ........................................................................................ 5 ASCVD prevention .................................................................................................................................... 7 Comorbidity treatment ............................................................................................................................... 7 Follow-up/Monitoring ..................................................................................................................................... 8 Periodic monitoring of conditions and complications ................................................................................ 8 Medication monitoring ............................................................................................................................. 10 Recommended comorbidity screening .................................................................................................... 10 Recommended immunizations ................................................................................................................ 10 Evidence Summary ..................................................................................................................................... 11 References .................................................................................................................................................. 15 Guideline Development Process and Team ............................................................................................... 17 Appendix 1. Recommendation Grade Labels ............................................................................................. 18
Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient.
Type 2 Diabetes Screening and Treatment Guideline Copyright 19962013 Group Health Cooperative. All rights reserved.
Prevention
Studies have shown that increasing physical activity and eating a healthy diet can significantly delay the onset of type 2 diabetes, including for patients diagnosed with impaired glucose tolerance. Studies have also shown the use of metformin can delay the diagnosis of diabetes for patients with impaired glucose intolerance, but there is no evidence that either metformin or valsartan leads to long-term better clinical outcomes for patients.
Test(s) Fasting plasma glucose or HbA1c Fasting plasma glucose or HbA1c HbA1c HbA1c 2-hour glucose tolerance
Men and nonpregnant women with impaired fasting glucose Expert opinion Nonpregnant women with a history of gestational diabetes Pregnant women (See the Group Health Gestational Diabetes Guideline)
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Annually
The available evidence does not suggest an ideal screening frequency. Group Health recommends screening of adults with hypertension every 2 years.
The American Diabetes Association recommends screening patients who are overweight or obese (BMI of 25 or higher) and who have additional risk factors for diabetes (Table 4 on page S1 4), such as highrisk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander); family history of one or more first-degree relatives with type 2 diabetes; or history of polycystic ovarian disease. The U.S. Preventive Services Task Force does not make the same recommendation, but it is reasonable to have a higher clinical index of suspicion for type 2 diabetes among adults with multiple risk factors and to use clinical judgment or shared decision making about whether to screen.
Diagnosis
Diagnosis for an asymptomatic patient requires 2 abnormal test results, which can be from the same test on different days, or from different tests on the same day or on different days. If only one comes back abnormal, then repeat the abnormal test on a different day. If it comes back abnormal again, then you have the diagnosis of diabetes. Diagnosis for a patient with classic symptoms of hyperglycemia (i.e., polyuria, polydipsia, weight loss) can be made with a single random plasma glucose result of 200 mg/dL or higher. A repeat measurement is not needed.
Table 2. Recommendations for diagnosing diabetes Test HbA1c Results 6.5% or higher 5.76.4% Lower than 5.7% Random plasma glucose 200 mg/dL or higher 140199 mg/dL Lower than 140 mg/dL Fasting plasma glucose 126 mg/dL or higher 100125 mg/dL Lower than 100 mg/dL
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Interpretation Diabetes Impaired glucose tolerance1 Normal Diabetes Impaired glucose tolerance1 Normal Diabetes Impaired glucose tolerance1 Normal
Impaired glucose tolerance (IGT) is similar to impaired fasting glucose (IFG) but is diagnosed with a confirmed oral glucose tolerance test (OGTT). Both IGT and IFG are risk factors for future diabetes and for cardiovascular disease. They are sometimes jointly referred to as pre-diabetes. Group Health recommends avoiding the term pre-diabetes because not all patients with IGT and/or IFG will develop diabetes.
Patients with type 2 diabetes most commonly present as overweight, hyperglycemic, and nonketotic, with gradual onset of symptoms such as fatigue, blurred vision, polydipsia, and polyuria. Consider islet cell antibody (ICA) with reflex to glutamic acid decarboxylase antibody (GADA) testing for the following patient populations: Children and teenagers to distinguish early type 1 diabetes from type 2 diabetes. Older adults who are not overweight who are not responding well to oral hypoglycemic and lifestyle (diet/exercise) modification. The following laboratory tests are not recommended: Fasting C-peptide is not recommended because the test cannot distinguish well between people without diabetes and those with impaired endogenous insulin secretion. C-peptide is released from a person's pancreas in equimolar amounts to endogenous insulin. Because the amount of endogenous insulin secreted is dependent on a patient's blood glucose level, low or undetectable C-peptide levels may indicate either an inability to produce insulin or an absence of insulin secretion due to low blood sugar levels. In the latter case, a person without diabetes would not secrete much C-peptide and would have an abnormal test result. Plasma insulin is not recommended as it does not add any additional useful information.
Treatment
Goals
Cardiac risk reduction is the most important management issue for patients with diabetes. Table 3. Selected cardiac risk factors and goals for risk reduction Risk factor Blood pressure LDL cholesterol Hemoglobin A1c (HbA1c) Fasting blood glucose
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Goal Lower than 140/801 mm HG Lower than 100 mg/dL 78%2 80120 mg/dL
For patients with diabetes, there are two HEDIS goalslower than 140/90 and lower than 140/80. The Group Health guideline goal was changed to align with the lower HEDIS goal. Certain patientssuch as younger patients and those with microalbuminuriamay benefit from achieving even lower blood pressure levels (e.g., lower than 130/80). In older patients with type 2 diabetes, there is evidence that pushing systolic blood pressure below 120 mm Hg offers no more cardiovascular benefit than pushing it below 140 mm Hg. (ACCORD 2010). Intensive systolic blood pressure control to below 120 may lead to a higher rate of adverse effects. Use clinical judgment to determine if a target lower than 7% is appropriate for an individual patient. It can be challenging to push a patients HbA1c levels from just above 7% to below 7%. There are potential benefits (decreased nonfatal myocardial infarction) and potential harms (hypoglycemia, weight gain, and possible increase in all-cause and cardiovascular-cause mortality) of intensive glucose therapy, especially in patients with known cardiovascular disease. For frail elderly patients, a target HbA1c of 79% is reasonable.
There is fair evidence from one RCT that surgically induced weight loss results in better blood glucose control and less need for diabetic medications than conventional diabetes therapy focused on weight loss through lifestyle changes. There is insufficient evidence on long-term effectiveness and safety (Dixon 2008). See the Group Health clinical review criteria for bariatric surgery (http://www.ghc.org/allsites/clinical/criteria/pdf/baricrit1.pdf). See the Group Health Weight Management Guideline for recommendations and further information.
Foot care
For patients at very high risk or increased risk of developing foot ulcers, recommend using a foot skin care kit (https://provider.ghc.org/open/caringForOurMembers/patientHealthEducation/conditionsDiseases/diabete s/footCare.pdf). Foot-ulcer risk definitions: Patients at very high risk are those with a previous foot ulcer, amputation, or major foot deformity (claw/hammer toes, bony prominence, or Charcot deformity). Patients at increased risk are those who are insensate to 5.07 monofilament at any site on either foot or who have bunions, excessive corns, or callus. Patients at average risk are those with none of the aforementioned complications. Encourage patients to check their feet regularly and follow a self-management care agreement. If the patient or a family member cannot perform the patients foot care, encourage the patient to find someone who can provide assistance.
and/or
2nd
Add sulfonylureaNote Glimepiride 12 mg once daily at breakfast or first main meal (1 mg daily for elderly patients)
Prescribing notes Metformin Metformin should be titrated as tolerated. A reasonable initial titration schedule is: 500 mg tab once daily X 7 days; 500 mg 1 tab once daily X 7 days; 500 mg 1 tab twice daily If a patient does not experience any GI side effects after 23 days, dose may be titrated to goal more quickly. If a patient develops GI side effects, reduce dose and reassess. Consider a more conservative titration schedule starting with 500 mg tab (125 mg) PO once daily; alternatively, consider prescribing the XL formulation for patients who cannot tolerate ideal dose with regular release formulation. Precautions with metformin prescribing: Avoid use of metformin in patients with known binge or excessive alcohol use. Instruct patients to avoid excessive acute or chronic alcohol use. Suspend use of metformin if a patient is to undergo a surgical procedure or to be given iodinated contrast media for a radiological procedure. Restart metformin when normal renal function is verified. Metformin should be withheld in patients with dehydration and/or prerenal azotemia. NPH insulin Check fasting blood glucose (FBG) every day and get weekly average. Target is mean FBG of 120 mg/dL. Less than 200 lb, FBG lower than 200 12 U and up by 4 U/week Less than 200 lb, FBG higher than 200 16 U and up by 8 U/ week More than 200 lb, FBG lower than 200 20 U and up by 4 U/ week More than 200 lb, FBG higher than 200 30 U and up by 10 U/ week Treat-to-target strategy: 1. Initial dose of 10 units of long-acting insulin at bedtime. 2. If FBG is higher than 130, increase bedtime insulin dose by 1 unit. 3. Continue increasing bedtime insulin dose by 1 unit at a time until FBG is in the target range. 4. If FBG is lower than 80, decrease bedtime insulin dose by 1 unit. 5. Continue decreasing bedtime insulin dose by 1 unit at a time until FBG is in the target range. If HbA1c is higher than 7.0% and BG checks before lunch, dinner, and bedtime are indicating a steady rise in BG throughout the day, the patient very likely needs daytime insulin therapy. Sulfonylurea For preferred sulfonylurea (Glimepiride), a reasonable titration schedule is: Increase to 2 mg once daily for 12 weeks; Increase by 2 mg once daily at 1- to 2-week intervals to maximum of 8 mg once daily. For alternative sulfonylurea (Glipizide), a reasonable titration schedule is: 5 mg tab twice daily X 7 days; 5 mg 1 tab twice daily X 7 days; 5 mg 2 tab twice daily X 7 days Consider prescribing the XL formulation for patients who cannot tolerate regular release formulation.
U-500 insulin
Consider U-500 insulin for patients who are very insulin resistant and need more than 200 units of insulin per day. Consult with a diabetes expert before switching to U-500 insulin. Within Group Health, contact Dave McCulloch, MD, Dan Kent, PharmD, or a Diabetes Expert Team physician. See Regular Insulin U500: Considerations for Safe Use for more information.
ASCVD prevention
Risk-reduction measures to consider include smoking cessation, blood pressure control, statin therapy, ACE inhibitor/angiotensin receptor blocker (ARB) therapy, and antiplatelet therapy. See the Group Health Cardiovascular Disease (ASCVD) Guideline for details.
Comorbidity treatment
Hypertension management
First-line treatment for patients with diabetes and hypertension is an ACE inhibitor or an ARB. See the Group Health Hypertension Guideline for details.
Sick-day management
Patients experiencing acute illnesses need to be extra vigilant about blood glucose monitoring and control. Within Group Health, the following information and help is available: The Pharmacy's It's Flu Season! Timely Reminders About Diabetes and Sick Day Care contains information about the Sick Day Kit, which is available to patients. The pamphlet Living Well with Type 2 Diabetes: Taking Care of Yourself When Youre Sick" (#338) can be ordered from the Group Health Resource Line (or use SmartPhrase .chronicdiseasedmtype2sickdayplan). Group Health pharmacy staff can help with selecting sugar-free cold medicines and cough syrups.
Follow-up/Monitoring
Periodic monitoring of conditions and complications
Table 5. Self blood glucose monitoring (SBGM) Note that for patients with diabetes, SBGM is useful only if they are testing and using the result information to make changes to their diabetes self-management plans. Eligible population Patients on lifestyle changes and/or metformin only Recommendations These patients are at no risk for hypoglycemia.1 It is perfectly reasonable for them not to do SBGM. Changes to therapy can be made based on HbA1c values every 3 months. Specifically, some patients may find SBGM helps them to stay motivated with lifestyle changes to see the effect of particular food items or exercise on their blood glucose. These patients may develop hypoglycemia. It is advisable that they do SBGM when they feel funny to confirm whether or not their symptoms are due to hypoglycemia. If patients are using treat-to-target approaches, especially if using insulin (for example, titrating their dose of bedtime NPH insulin until they reach a fasting blood glucose target of 120 mg/dL), then testing the fasting blood glucose once a day is advisable. Once patients achieve their fasting blood glucose target, there is no need to continue testing every morning if they feel well and their HbA1c stays below their target range. However, if such patients are at their target for fasting blood glucose but their HbA1c is still above target, then testing before and two hours after their main meal may give useful information about the need for additional daytime treatment (with sulfonylurea or insulin). These patients should test 34 times daily if they are using the information to adjust how much fast-acting insulin they take before the meal. They may also want to test 2 hours after their main meal or under other circumstances where they want to know the effect of food, exercise, or stress on their blood glucose levels.
Several studies have shown that improvement in HbA1c is almost identical whether patients test their blood glucose or not (Poolsup 2009).
Table 6. Recommended periodic monitoring of conditions and complications Condition/complication Hypertension Blood glucose control Test(s) Frequency BP taken with appropriate size cuff Every visit using optimal technique HbA1c Every 3 months until the target level is reached; thereafter, patient should be monitored every 6 months. Patients at very high risk2 should be seen every 3 months by a wound care nurse. Patients at increased risk2 and average risk2 should be screened annually. Annually Annually Patients with evidence of retinopathy should be screened annually. Grade A Patients without evidence of retinopathy should be screened every 2 years.3 Grade A At least annually
Foot ulcers
Physical exam focused on ankle reflexes, dorsalis pedis pulse, vibratory sensation, and 5.07 monofilament touch sensation performed by a provider qualified to determine the level of risk for foot ulcers Spot urine (microalbuminuria: creatinine ratio)1 Fasting LDL Dilated eye exam by a trained eye services professional or Non-dilated digital photography followed by a comprehensive exam for those who test positive Serum creatinine and Serum potassium
The spot urine test (microalbuminuria/creatinine ratio) can identify patients with microalbuminuria by giving a quantitative estimate of protein loss that correlates with 24-hour urinary protein measurements. Test results are expressed in micrograms of urinary albumin per milligram of urinary creatinine (or A:C ratio). Group Health defines a positive test as more than 50 mcg/mg. Although the conventional definition of microalbuminuria is more than 30 mcg/mg, using more than 50 mcg/mg minimizes the number of false-positive results. Two positive (more than 50 mcg/mg) spot urine tests are diagnostic for microalbuminuria. See Foot care in the Lifestyle modifications and non-pharmacologic options section for foot-ulcer risk definitions. Annual screening is not recommended because the benefits of more frequent screening are marginal: For every 1,000 persons screened annually (instead of every second year), one additional case of proliferative diabetic retinopathy and one additional case of clinically significant macular edema will be detected.
Medication monitoring
Table 7. Recommended monitoring for medication side effects Eligible population Patients who are being treated with metformin1
1
Frequency Annually if serum creatinine is 1.5 or lower or Twice a year if serum creatinine is higher than 1.5
For patients on metformin, serum creatinine should be monitored because the medication is primarily excreted by the kidney. Metformin can be prescribed if the serum creatinine is lower than 2.5 and if the eGFR is higher than 30, provided this value is not 25% worse than the previous reading. Use of concomitant medications that may affect renal function (i.e., affect tubular secretion) may also affect metformin excretion. Metformin should be withheld in patients with dehydration and/or prerenal azotemia; also hold prior to radiologic procedures (i.e., studies requiring administration of IV contrast) and prior to surgery.
Recommended immunizations
Table 8. Recommended immunizations for patients with diabetes1 Immunization Influenza Pneumococcal (PPV23) Hepatitis B1
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Frequency Annually, as early as possible when vaccine becomes available Once between 19 and 64 years Booster after 65 years (5-year minimal interval) Three-dose series for 19 to 59 years 60 years and older, depending on risk
See the CDCs Recommended Adult Immunization Schedule for more detailed information (http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf). Results from observational studies suggest that patients with diabetes are at higher risk for hepatitis B compared to patients without diabetes (CDC 2011).
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Evidence Summary
Group Health developed the Type 2 Diabetes Screening and Treatment Guideline using an evidencebased process, including systematic literature search, critical appraisal, and evidence synthesis.
Prevention
Pharmacologic treatment to delay diabetes
Metformin Results from a recent meta-analysis of 31 randomized controlled trials (RCTs) illustrated that treatment with metformin reduced the absolute risk of diabetes by 6% during a mean duration of 1.8 years. Subjects receiving metformin also experienced modest improvements in BMI, LDLcholesterol, and HDL-cholesterol compared to subjects receiving either placebo or no intervention (Salpeter 2008). The study analyzed metabolic risk factors and not clinical outcomes, leaving unanswered the question of whether delaying diabetes improves clinical outcomes. Valsartan There is fair evidence from an RCT that the use of valsartan, an angiotensin-receptor blocker (ARB), along with lifestyle modification, led to a 14% relative reduction in the incidence of diabetes compared to lifestyle modification alone (NAVIGATOR 2010). However, there is not evidence that valsartan improves clinical outcomes.
Diagnosis
Use of HbA1c to diagnose diabetes
A cross-sectional study compared HbA1c of 6.5% or higher and fasting plasma glucose (FPG) of 126 mg/dL or higher for the identification of undiagnosed diabetes among National Health and Nutrition Examination Survey (NHANES) participants. When using HbA1c of 6.5% or higher and FPG of 126 mg/dL or higher as the cut-points for diabetes, results showed that there is moderate agreement between the two tests for the diagnosis of diabetes. Diabetes classification was consistent for the majority of the subjects, with 95.9% being classified as positive by both tests and 1.8% being classified as negative by both tests. Only 0.5% of subjects were classified as positive by one test and negative by the other (Carson 2010).
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Treatment
Goals
Blood pressure There is good evidence from one RCT that intensive lowering of systolic blood pressure below 120 mm Hg did not reduce the combined risk of fatal or nonfatal cardiovascular events (ACCORD 2010, NEJM p. 1575). Blood glucose control Three meta-analyses compared the effects of tight blood glucose control versus standard therapy (Turnbull 2009, Kelly 2009, Ray 2009). Tight blood glucose control appears to reduce the risk of nonfatal myocardial infarction; however, there is an increased risk of hypoglycemia and weight gain. Additionally, the ACCORD trial suggests that all-cause mortality is increased with intensive treatment compared to standard treatment (ACCORD, NEJM 2008). Results from an exploratory post hoc analysis from the ACCORD trial suggest that this trend may be even more striking among patients with baseline HbA1c levels higher than 8.5% and those with neuropathy (CallesEscandon 2010). There is evidence from two major RCTs, the Diabetes Control and Complications Trial (DCCT) for type 1 diabetes and the UK Prospective Diabetes Study for type 2 diabetes (UKPDS), that blood glucose control delays the onset and slows the progression of diabetic retinopathy (DCCT 1993, UKPDS Lancet 1998). Both studies randomized patients with diabetes to receive intensive blood glucose control or conventional treatment. The DCCT found that among patients with no retinopathy at study entry, intensive blood glucose control therapy reduced the risk of progression of retinopathydefined as a sustained change on retinal photographyby 3.5% per year (NNT = 29). However, the reduction in the risk of retinopathy progression associated with a lower HbA1c was accompanied by an increased risk of hypoglycemia. For patients with mild retinopathy at the beginning of the DCCT, intensive therapy reduced the risk of laser treatment of retinopathy by 1.4% per year (NNT = 71). Target HbA1c There were no randomized controlled trials that addressed the appropriate HbA1c levels for patients with type 2 diabetes. Evidence pertaining to target HbA1c levels comes from a retrospective cohort study that was designed to address the association between all-cause mortality and HbA1c levels. Results from this study showed that for those in cohort 1 (metformin plus sulfonylurea), subjects with HbA1c levels lower than 6.72% or higher than 9.85% were at increased risk for all-cause mortality. For those in cohort 2 (insulin regimen), subjects with HbA1c levels lower than 7.4% or higher than 9.12% were at increased risk for all-cause mortality (Currie 2010).
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Exercise
A meta-analysis of 14 RCTs on exercise in patients with type 2 diabetes showed an improvement in HbA1c of 0.6 points (95% CI = 0.3 to 0.9 points). The duration of exercise training ranged from 8 weeks to 12 months (Thomas 2006).
Bariatric surgery
There is fair evidence from one RCT that surgically induced weight loss results in better blood glucose control and less need for diabetic medications than conventional diabetes therapy focused on weight loss through lifestyle changes. There is insufficient evidence on long-term effectiveness and safety (Dixon 2008).
Follow-up/monitoring
Microalbuminuria
There is no direct evidence from randomized or non-randomized controlled screening trials that microalbuminuria screening improves health outcomes. The recommendation for microalbuminuria screening is based on indirect evidence that the natural history of diabetic renal disease is well known, that screening can identify early disease, and that treatment of patients with microalbuminuria has been shown to improve health outcomes. According to data from the UK Prospective Diabetes Study (UKPDS), for patients newly diagnosed with type 2 diabetes, the annual rate of progression from no nephropathy to microalbuminuria is 2% and from microalbuminuria to macroalbuminuria is 2.8% (Adler 2003).
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Neuropathy
There is fair evidence that diabetic foot screening prevents adverse outcomes. One RCT reported outcomes in patients with diabetes assigned to a foot screening and protection program versus outcomes in those receiving usual care. At the end of 2 years, there were significantly fewer amputations in the footscreening group, but no significant difference in the incidence of ulcers. The number needed to screen (NNS) to prevent one amputation = 63 and to prevent one major amputation = 91 (McCabe 1998). No RCTs attempting to replicate these findings were identified.
Retinopathy
There is no direct evidence from randomized or non-randomized controlled screening trials that retinal screening improves health outcomes. The recommendation for retinal screening is based on indirect evidence: namely, that the natural history of diabetic retinal disease is well known, that screening can identify early disease, and that treatments such as blood glucose control and laser therapy have been shown to improve health outcomes. Two cohort studies investigated the optimum screening interval by grade of retinopathy. Both studies found that for patients at low risk for retinopathy, a 2-year screening interval was not associated with increased risk (Younis 2003, Misra 2009). Non-mydriatic digital stereoscopic retinal imaging A recent meta-analysis that included 20 observational studies and 4,059 patients examined how mydriasis influenced the accuracy of screening for diabetic retinopathy. Findings from this analysis suggest that mydriatic status alone did not significantly influence the sensitivity or specificity to detect any diabetic retinopathy (Bragge 2011). Results from an observational study that examined the sensitivity and specificity of non-mydriatic digital stereoscopic retinal imaging (NMDSRI) compared to dilated retinal examination performed by an ophthalmologist or an optometrist found that NMDSRI has a sensitivity of 98% and a specificity of 100% for retinopathy within one grade of that indicated by dilated retinal exam (Ahmed 2006). These findings were supported by the results of several other observational studies (Aptel 2008, Boucher 2003, Lin 2002, Vujosevic 2009).
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References
Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545-2559. ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575-1585. Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR; UKPDS Group. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int. 2003;63(1):225-232. Ahmed J, Ward TP, Bursell SE, Aiello LM, Cavallerano JD, Vigersky RA. The sensitivity and specificity of nonmydriatic digital stereoscopic retinal imaging in detecting diabetic retinopathy. Diabetes Care. 2006;29(10):22052209. Aptel F, Denis P, Rouberol F, Thivolet C. Screening of diabetic retinopathy: effect of field number and mydriasis on sensitivity and specificity of digital fundus photography. Diabetes Metab. 2008;34(3):290-293. Boucher MC, Gresset JA, Angioi K, Olivier S. Effectiveness and safety of screening for diabetic retinopathy with two nonmydriatic digital images compared with the seven standard stereoscopic photographic fields. Can J Ophthalmol. 2003;38(7):557-568. Bragge P, Gruen RL, Chau M, Forbes A, Taylor HR. Screening for presence or absence of diabetic retinopathy: a meta-analysis. Arch Ophthalmol. 2011;129(4):435-444. Calles-Escandon J, Lovato LC, Simons-Morton DG, et al. Effect of intensive compared with standard glycemia treatment strategies on mortality by baseline subgroup characteristics: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Diabetes Care. 2010;33(4):721-727. Carson AP, Reynolds K, Fonseca VA, Muntner P. Comparison of A1c and fasting glucose criteria to diagnose diabetes among U.S. adults. Diabetes Care. 2010(1);33:95-97. Centers for Disease Control and Prevention (CDC). Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2011;60(50):1709-1711. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005;352(24):2477-2486. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective study. Lancet. 2010;375(9713):481-489. DeFronzo RA, Goodman AM. Efficacy of metformin in patients with non-insulin-dependent diabetes mellitus.The Multicenter metformin Study Group. N Engl J Med. 1995;333(9):541-549. The Diabetes Control and Complications Trial Research Group (DCCT). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986. Dixon JB, OBrien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008;299(3):316-323. Guare JC, Wing RR, Marcus MD, et al. Analysis of changes in eating behavior and weight loss in type II diabetic patients: which behaviors to change. Diabetes Care. 1989;12(7):500-503. Kelly TN, Bazzano LA, Fonseca VA, Thethi TK, Reynolds K, He J. Systematic review: glucose control and cardiovascular disease in type 2 diabetes. Ann Intern Med. 2009;151(6):394-403. Lin DY, Blumenkranz MS, Brothers RJ, Grosvenor DM. The sensitivity and specificity of single-field nonmydriatic monochromatic digital fundus photography with remote image interpretation for diabetic retinopathy screening: a comparison with ophthalmoscopy and standardized mydriatic color photography. Am J Ophthalmol. 2002;134(2):204213. Type 2 Diabetes Screening and Treatment Guideline 15
McCabe CJ, Stevenson RC, Dolan AM. Evaluation of a diabetic foot screening and protection programme. Diabet Med. 1998;15(1):80-84. Misra A, Bachmann O, Greenwood RH, et al. Trends in yield and effects of screening intervals during 17 years of a large UK community-based diabetic retinopathy screening programme. Diabet Med. 2009;26(10):1040-1047. NAVIGATOR Study Group. Effect of valsartan on the incidence of diabetes and cardiovascular events. N Engl J Med. 2010;362(16):1477-1490. OKane MJ, Bunting B, Copeland M, Coates VE; EMSON study group. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial. BMJ. 2008;336(7654):1174-1177. Poolsup N, Suksomboon N, Rattanasookchit S. Meta-analysis of the benefits of self-monitoring of blood glucose on glycemic control in type 2 diabetes patients: an update. Diabetes Technol Ther. 2009;11(12):775-784. Ray KK, Seshasai SR, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet. 2009;373(9677):1765-1772. Salpeter SR, Buckley NS, Kahn JA, Salpeter EE. Meta-analysis: metformin treatment in persons at risk for diabetes mellitus. Am J Med. 2008;121(2):149-157. Siebenhofer A, Plank J, Berghold A, et al. Short acting insulin analogues versus regular human insulin in patients with diabetes mellitus. Cochrane Database Syst Rev. 2006;(2):CD003287. Singh SR, Ahmad F, Lal A, Yu C, Bai Z, Bennett H. Efficacy and safety of insulin analogues for the management of diabetes mellitus: a meta-analysis. CMAJ. 2009;180(4):385-397. Thomas DE, Elliott EJ, Naughton GA. Exercise for type 2 diabetes mellitus. Cochrane Database Syst Rev. 2006;(3):CD002968. Turnbull FM, Abraira C, Anderson RJ, et al. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia. 2009;52(11):2288-2298. UK Prospective Diabetes Study Group. UK Prospective Diabetes Study 7: Response of fasting plasma glucose to diet therapy in newly presenting type II diabetic patients. Metabolism. 1990;39(9):905-912. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-853. U.S. Preventive Services Task Force. Screening for type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008;148(11):846-854. Vujosevic S, Benetti E, Massignan F, et al. Screening for diabetic retinopathy: 1 and 3 nonmydriatic 45-degree digital fundus photographs vs 7 standard early treatment diabetic retinopathy study fields. Am J Ophthalmol. 2009;148(1):111-118. Wing RR, Jeffery RW, Burton LR, Thorson C, Nissinoff KS, Baxter JE. Food provision vs. structured meal plans in the behavioral treatment of obesity. Int J Obes Relat Metab Disord. 1996;20(1):56-62. Wood PD, Stefanick ML, Williams PT, Haskell WL. The effects on plasma lipoproteins of a prudent weight-reducing diet, with or without exercise, in overweight men and women. N Engl J Med. 1991;325(7):461-466. Younis N, Broadbent D, Vora JP, Harding SP. Incidence of sight-threatening retinopathy in patients with type 2 diabetes in the Liverpool Diabetes Eye Study: a cohort study. Lancet. 2003;361(9353):195-200. Zeller M, Danchin N, Simon D, et al; French Registry of Acute ST-Elevation and Non-ST-Elevation Myocardial Infarction investigators. Impact of type of preadmission sulfonylureas on mortality and cardiovascular outcomes in diabetic patients with acute myocardial infarction. J Clin Endocrinol Metab. 2010;95(11):4993-5002.
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Grade D I statement
Expert opinion
Moderate
Low
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